Sonshine Companion Care Independence Contractor Application Applicant Information: Last Name: First Name: I Middle Name: Other alias, if applicable: Street Address: Apt./Unit #: City: State: I Zip: I Phone: DOB: SSN: Gender: I Race: Other Language(s) spoken, if applicable: Email Address: Alternate Phone: Position Applied For: Are you a citizen of the United Yes ( ) No () If No, are you authorized I Yes ( ) No ( ) States? to work in the U.S? Have you ever worked for this Yes ( ) No () If so, when? company before? Have you ever been convicted of a Yes ( ) No () If yes, explain: felony? Previous Company Name: Supervisor Name: Contact# Job Title: Employment: Job 1 Job 2 Job 3 Military Service: Branch: From: To: Rank At Discharge: Type Of Discharge: If other than honorable, explain: References: Certification(s): Company: Supervisor: Phone: sec USE ONLY Dates of hire: Rehire: Notes: Dates of hire: Rehire: Notes: Dates of hire: Rehire: Notes: I certify that my answers are true and complete to the best of my knowledge. Signature: Date:
Sonshine Companion Care Telephone Reference Check Form Applicant Information Applicant Name: ------------------------- Last First M.I. Date: Position Applied for: Contact Information Name of Contact: Title: Phone: Company: START DATE: END DATE: Reference Comments What was the applicant's position on the last day of employment? Rehire Elgibility: Contact Information Name of Contact: Title: Company: ------------------ Phone: START DATE: END DATE: What was the applicant's position on the last day of employment? Reference Comments Rehire Eligibility: Contact Information Name of Contact: Title: Company: ------------------ START DATE: END DATE: What was the applicant's position on the last day of employment? Reference Comments Phone: Rehire Eligibility: Completed by: Date:
FAVORITES SHEET Name: ---------- Bi rt h date: Favorite gift you ever received: Favorite pet : Favorite candy:. Favorite soda: Favorite music genre: Favorite movie genre: Favorite food: Favorite activity(ies) currently:. I am motivated by these following things (place a 1 by the one that is most true, then a 2 then a 3 then a 4 by the one that applies the least): Control Peace Fun Helping Others The following questions are true or false: I am an introvert? T I am an extrovert? T -- F I like to stick only to the facts. T F I like to be on a strict schedule. T F I am a compassionate person. F T F I am flexible and spontaneous. T F I am happiest when: I am saddest when: I would like to be taken to:----------------------- If I could sign up for a class or activity I'd sign up for:.
RICK SCOTT GOVERNOR Better Health Care for all Floridians ELIZABETH DUDEK SECRETARY PRIVACY POLICY ACKNOWLEDGEMENT FORM I acknowledge that I have received a copy of the privacy policies from the Florida Department of Law Enforcement and the Federal Bureau of Investigation, which describe the exchange of information where criminal record results will become part of the Care Provider Background Screening Clearinghouse. I understand and agree that I will read and comply with the guidelines contained in the privacy policies. Employee/Contractor Name (Printed) Employee/Contractor Signature Date 272 7 M ah an D r i v e, MS # 4 0 T al l a has s ee, F l or i da 3 23 08 V i s i t A H C A onl i n e at A H C A. M y F l or i da. c om
ATTESTATION OF COMPLIANCE with Background Screening Requirements Authority: This form may be used by all employees to comply with: the attestation requirements of section 435.05(2), Florida Statutes, which state that every employee required to undergo Level 2 background screening must attest, subject to penalty of perjury, to meeting the requirements for qualifying for employment pursuant to this chapter and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses while employed by the employer; AND the proof of screening within the previous 5 years in section 408.809(2), Florida Statutes which requires proof of compliance with level 2 screening standards that have been screened through the Care Provider Background Screening Clearinghouse created under Section 435.12, F.S., or screened within the previous 5 years by the Agency, Department of Health, Department of Elder Affairs, the Agency for Persons with Disabilities, Department of Children and Families, or the Department of Financial Services for an applicant for a certificate of authority to operate a continuing care retirement community under Chapter 651, F.S., and in accordance with the standards in Section 408.809(2), F.S., if that agency is not currently implemented in the Care Provider Background Screening Clearinghouse. This form must be maintained in the employee s personnel file. If this form is used as proof of screening for an administrator or chief financial officer to satisfy the requirements of an application for a health care provider license, please attach a copy of the screening results and submit with the licensure application. Employee/Contractor Name: Health Care Provider/ Employer Name: Address of Health Care Provider: I hereby attest to meeting the requirements for employment and that I have not been arrested for or been found guilty of, regardless of adjudication, or entered a plea of nolo contendere, or guilty to any offense, or have an arrest awaiting a final disposition prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction: Criminal offenses found in section 435.04, F.S. (a) Section 393.135, relating to sexual misconduct with certain developmentally disabled clients and reporting of such sexual misconduct. (b) Section 394.4593, relating to sexual misconduct with certain mental health patients and reporting of such sexual misconduct. (c) Section 415.111, relating to adult abuse, neglect, or exploitation of aged persons or disabled adults. (d) Section 777.04, relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection. (e) Section 782.04, relating to murder. (f) Section 782.07, relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child. (g) Section 782.071, relating to vehicular homicide (h) Section 782.09, relating to killing of an unborn quick child by injury to the mother. (i) Chapter 784, relating to assault, battery, and culpable negligence, if the offense was a felony. (j) Section 784.011, relating to assault, if the victim of the offense was a minor. (k) Section 784.03, relating to battery, if the victim of the offense was a minor. (l) Section 787.01, relating to kidnapping. AHCA Form # 3100-0008,May 2015 Rule 59A-35.090 Page 1 of 4 Form available at: http://ahca.myflorida.com/backgroundscreening
Form W-9 (Rev. December 2014) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. Give Form to the requester. Do not send to the IRS. Print or type See Specific Instructions on page 2. 2 Business name/disregarded entity name, if different from above 3 Check appropriate box for federal tax classification; check only one of the following seven boxes: Individual/sole proprietor or single-member LLC C Corporation S Corporation Partnership Trust/estate Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner. Other (see instructions) 5 Address (number, street, and apt. or suite no.) 6 City, state, and ZIP code 4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (if any) Exemption from FATCA reporting code (if any) (Applies to accounts maintained outside the U.S.) Requester s name and address (optional) 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter. Part II Certification Under penalties of perjury, I certify that: Social security number or Employer identification number 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3. Sign Here Signature of U.S. person General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following: Form 1099-INT (interest earned or paid) Form 1099-DIV (dividends, including those from stocks or mutual funds) Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) Form 1099-S (proceeds from real estate transactions) Form 1099-K (merchant card and third party network transactions) Date Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) Form 1099-C (canceled debt) Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2. By signing the filled-out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and 4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information. Cat. No. 10231X Form W-9 (Rev. 12-2014)
(m) Section 787.02, relating to false imprisonment. (n) Section 787.025, relating to luring or enticing a child. (o) Section 787.04(2), relating to taking, enticing, or removing a child beyond the state limits with criminal intent pending custody proceedings. (p) Section 787.04(3), relating to carrying a child beyond the state lines with criminal intent to avoid producing a child at a custody hearing or delivering the child to the designated person. (q) Section 790.115(1), relating to exhibiting firearms or weapons within 1,000 feet of a school. (r) Section 790.115(2)(b), relating to possessing an electric weapon or device, destructive device, or other weapon on school property. (s) Section 794.011, relating to sexual battery. (t) Former s. 794.041, relating to prohibited acts of persons in familial or custodial authority. (u) Section 794.05, relating to unlawful sexual activity with certain minors. (v) Chapter 796, relating to prostitution. (w) Section 798.02, relating to lewd and lascivious behavior. (x) Chapter 800, relating to lewdness and indecent exposure. (y) Section 806.01, relating to arson. (z) Section 810.02, relating to burglary. (aa) Section 810.14, relating to voyeurism, if the offense is a felony. (bb) Section 810.145, relating to video voyeurism, if the offense is a felony. (cc) Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony. (dd) Section 817.563, relating to fraudulent sale of controlled substances, only if the offense was a felony. (ee) Section 825.102, relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult. (ff) Section 825.1025, relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult. (gg) Section 825.103, relating to exploitation of an elderly person or disabled adult, if the offense was a felony. (hh) Section 826.04, relating to incest. (ii) Section 827.03, relating to child abuse, aggravated child abuse, or neglect of a child (jj) Section 827.04, relating to contributing to the delinquency or dependency of a child. (kk) Former s. 827.05, relating to negligent treatment of children. (ll) Section 827.071, relating to sexual performance by a child. (mm) Section 843.01, relating to resisting arrest with violence. (nn) Section 843.025, relating to depriving a law enforcement, correctional, or correctional probation officer means of protection or communication. (oo) Section 843.12, relating to aiding in an escape. (pp) Section 843.13, relating to aiding in the escape of juvenile inmates in correctional institutions. (qq) Chapter 847, relating to obscene literature. (rr) Section 874.05(1), relating to encouraging or recruiting another to join a criminal gang. (ss) Chapter 893, relating to drug abuse prevention and control, only if the offense was a felony or if any other person involved in the offense was a minor. (tt) Section 916.1075, relating to sexual misconduct with certain forensic clients and reporting of such sexual misconduct. (uu) Section 944.35(3), relating to inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm. (vv) Section 944.40, relating to escape. (ww) Section 944.46, relating to harboring, concealing, or aiding an escaped prisoner. (xx) Section 944.47, relating to introduction of contraband into a correctional facility. (yy) Section 985.701, relating to sexual misconduct in juvenile justice programs. (zz) Section 985.711, relating to contraband introduced into detention facilities. (3) The security background investigations under this section must ensure that no person subject to this section has been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense that constitutes domestic violence as defined in s. 741.28, whether such act was committed in this state or in another jurisdiction. AHCA Form # 3100-0008,May 2015 Rule 59A-35.090 Page 2 of 4 Form available at: http://ahca.myflorida.com/backgroundscreening
Criminal offenses found in section 408.809(4), F.S. (a) Any authorizing statutes, if the offense was a felony. (b) This chapter, if the offense was a felony. (c) Section 409.920, relating to Medicaid provider fraud. (d) Section 409.9201, relating to Medicaid fraud. (e) Section 741.28, relating to domestic violence. (f) Section 777.04, relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection. (g) Section 817.034, relating to fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems. (h) Section 817.234, relating to false and fraudulent insurance claims. (i) Section 817.481, relating to obtaining goods by using a false or expired credit card or other credit device, if the offense was a felony. (j) Section 817.50, relating to fraudulently obtaining goods or services from a health care provider. (k) Section 817.505, relating to patient brokering. (l) Section 817.568, relating to criminal use of personal identification information. (m) Section 817.60, relating to obtaining a credit card through fraudulent means. (n) Section 817.61, relating to fraudulent use of credit cards, if the offense was a felony. (o) Section 831.01, relating to forgery. (p) Section 831.02, relating to uttering forged instruments. (q) Section 831.07, relating to forging bank bills, checks, drafts, or promissory notes. (r) Section 831.09, relating to uttering forged bank bills, checks, drafts, or promissory notes. (s) Section 831.30, relating to fraud in obtaining medicinal drugs. (t) Section 831.31, relating to the sale, manufacture, delivery, or possession with the intent to sell, manufacture, or deliver any counterfeit controlled substance, if the offense was a felony (u) Section 895.03, relating to racketeering and collection of unlawful debts. (v) Section 896.101, relating to the Florida Money Laundering Act. I have been granted an Exemption from Disqualification through the Agency for Healthcare Administration (AHCA). Date of Decision: I have been granted an Exemption from Disqualification through the Florida Department of Health. Date of Decision: **A copy of the Exemption from Disqualification decision letter must be attached** If you are also using this form to provide evidence of prior Level 2 screening (fingerprinting) in the last 5 years and have not been unemployed for more than 90 days, please provide the following information. A copy of the prior screening results must be attached. Purpose of Prior Screening: Screening conducted by: Agency for Healthcare Administration Department of Health Agency for Persons with Disabilities Date of Prior Screening: Department of Elder Affairs Department of Financial Services Department of Children and Family Services AHCA Form # 3100-0008,May 2015 Rule 59A-35.090 Page 3 of 4 Form available at: http://ahca.myflorida.com/backgroundscreening
Attestation Under penalty of perjury, I,, hereby swear or affirm that I meet the requirements for qualifying for employment in regards to the background screening standards set forth in Chapter 435 and section 408.809, F.S. In addition, I agree to immediately inform my employer if arrested or convicted of any of the disqualifying offenses while employed by any health care provider licensed pursuant to Chapter 408, Part II F.S. Employee/Contractor Signature Title Date AHCA Form # 3100-0008,May 2015 Rule 59A-35.090 Page 4 of 4 Form available at: http://ahca.myflorida.com/backgroundscreening
FLORIDA DEPARTMENT OF LAW ENFORCEMENT NOTICE FOR APPLICANTS SUBMITTING FINGERPRINTS WHERE CRIMINAL RECORD RESULTS WILL BECOME PART OF THE CARE PROVIDER BACKGROUND SCREENING CLEARINGHOUSE NOTICE OF: SHARING OF CRIMINAL HISTORY RECORD INFORMATION WITH SPECIFIED AGENCIES, RETENTION OF FINGERPRINTS, PRIVACY POLICY, AND RIGHT TO CHALLENGE AN INCORRECT CRIMINAL HISTORY RECORD This notice is to inform you that when you submit a set of fingerprints to the Florida Department of Law Enforcement (FDLE) for the purpose of conducting a search for any Florida and national criminal history records that may pertain to you, the results of that search will be returned to the Care Provider Background Screening Clearinghouse. By submitting fingerprints, you are authorizing the dissemination of any state and national criminal history record that may pertain to you to the Specified Agency or Agencies from which you are seeking approval to be employed, licensed, work under contract, or to serve as a volunteer, pursuant to the National Child Protection Act of 1993, as amended, and Section 943.0542, Florida Statutes. "Specified agency" means the Department of Health, the Department of Children and Family Services, the Division of Vocational Rehabilitation within the Department of Education, the Agency for Health Care Administration, the Department of Elder Affairs, the Department of Juvenile Justice, and the Agency for Persons with Disabilities when these agencies are conducting state and national criminal history background screening on persons who provide care for children or persons who are elderly or disabled. The fingerprints submitted will be retained by FDLE and the Clearinghouse will be notified if FDLE receives Florida arrest information on you. Your Social Security Number (SSN) is needed to keep records accurate because other people may have the same name and birth date. Disclosure of your SSN is imperative for the performance of the Clearinghouse agencies duties in distinguishing your identity from that of other persons whose identification information may be the same as or similar to yours. Licensing and employing agencies are allowed to release a copy of the state and national criminal record information to a person who requests a copy of his or her own record if the identification of the record was based on submission of the person s fingerprints. Therefore, if you wish to review your record, you may request that the agency that is screening the record provide you with a copy. After you have reviewed the criminal history record, if you believe it is incomplete or inaccurate, you may conduct a personal review as provided in s. 943.056, F.S., and Rule 11C8.001, F.A.C. If national information is believed to be in error, the FBI should be contacted at 304-625-2000. You can receive any national criminal history record that may pertain to you directly from the FBI, pursuant to 28 CFR Sections 16.30-16.34. You have the right to obtain a prompt determination as to the validity of your challenge before a final decision is made about your status as an employee, volunteer, contractor, or subcontractor. Until the criminal history background check is completed, you may be denied unsupervised access to children, the elderly, or persons with disabilities. The FBI s Privacy Statement follows on a separate page and contains additional information.
1-789 (08-11-2010)